The Skin Cancer Foundation Journal

MAY 2014

The 2012 edition of The Skin Cancer Foundation Journal features medically reviewed, reader-friendly articles such as tanning, the increasing incidence of skin cancer diagnoses among young women, & the prevalence of melanoma among white males over 50.

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Staying on Top of Things B raun and Parlette made several more visits to the White House to check the wound, then continued to monitor the President for skin cancer, so over time, word got out that they had performed the procedure. For some reason, people were more interested in the Presi- dent's hair color than in any details of his skin cancer surgery. "They wanted to know if it was real or dyed," says Braun. "It was real. Mostly dark but with some gray — salt and pepper all the way through." They treated a second BCC on his nose on July 31, 1987, this time at the National Naval Medical Center. Basking in the President's glow, physicians from many diferent spe- cialties gathered around him, until Dr. Parlette took con- trol of the situation. He chased all the non-dermatologists out except for Dr. Hutton, saying "We dermatologists have work to do." As Nancy and Admiral Narva waited in the next room, Parlette and Braun anesthetized the President's nose and removed the frst Mohs layer. This time when the specimens were viewed under the microscope, residual BCC was found. So they removed a second layer, and found no additional tumor cells. Since the skin cancer had been in a more problematic spot, on the tip of the nose instead of the bridge and fairly large (12 mm diameter and 5 mm deep), it required some plastic surgery to cover the wound. Nancy se- cured the services of Dr. Diane Colgan, who had performed successful plastic surgery on Nancy. Dr. Colgan repaired the wound with a "transposition fap" (the Lindberg rhomboid fap), where layers taken from the immediately adjacent skin are formed into a fap to cover the wound. The surgery was entirely successful, and the wound healed uneventfully. Over the years, Dr. Parlette saw the President at the White M ohs surgery was developed in the 1940's by Dr. Frederick Mohs at the University of Wisconsin. The procedure evolved greatly over the years thanks to practitioners such as Perry Robins, MD, who taught several generations of Mohs surgeons, and the technique is now available in most parts of the US and around the world. Its advantage over standard surgical excision is that it re- moves the guesswork. With standard excision, surgeons take their best educated guess at how deep the skin cancer goes, cutting what they believe is a safe margin of healthy tissue around the tumor when they remove it. Sometimes they excise more healthy skin than necessary, causing excessive tissue destruction, and sometimes they remove too little tissue, inadvertently leaving can- cer cells. With Mohs surgery, the surgeon removes a thin layer of tissue, then carefully maps it and examines it under a microscope to see if any cancer cells remain on the edges, all while the patient waits in the doctor's offce or operating room. If the edges are clear, the surgery is concluded; if not, another thin layer of tissue is removed from where the map indicates remaining cancer cells; this new excised layer is similarly mapped and checked, and this technique is repeated until all the edges are seen to be clear of cancer. In this way, the least amount of healthy tissue is lost, and all cancerous tissue is defnitively removed. Why Mohs Surgery? House and at the Naval Hospital many more times. "It was always relaxed," Dr. Parlette recalls. "The President's casual sincerity was the same persona he projected to the public. He always greeted you with a warm smile, a hand- shake, and a joke … usually a good one, and we always laughed loudly, because when the President of the United States thinks his joke is funny, you do too." Dr. Parlette, continuing as the President's regular military dermatologist, found a couple more skin cancers over the years, and both he and Dr. Braun also several times used cryosurgery (a technique us- ing liquid nitrogen) to freeze of actinic keratoses. When the President wondered where these lesions kept coming from, Dr. Braun explained that they were skin precancers that might turn into skin cancers if not removed, and that they were caused by solar exposure like his BCCs were. The President begged to difer. " 'You know what I think?' he said, smiling. 'I think I'm not getting enough sun.' That was right in keeping with his typical sense of humor." 50 S K I N C A N C E R F O U N D A T I O N J O U R N A L Health President Reagan waves out the window of the National Naval Medical Center after colon cancer surgery, prior to his skin cancer surgery. Photo © Getty Images

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